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S3 L7 the Female Genital Tract

S3 L7 the Female Genital Tract

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Published by: 2013SecB on Jan 10, 2011
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Bien Ag Nina Ian John G Rachel Mark Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickie Ricobear

Teacher Dadang Ni a Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope

S3 L7: The Female Genital Tract by Dr. John Arnel Amata
I. Introduction a. Embryology b. Lateral Mullerian Ducts c. Pelvic Inflammatory Vulva a. Inflammatory Dermatologic Diseases b. Bartholin Cyst c. Vestibular adenitis d. Non neoplastic epithelial disorders e. Tumors Vagina a. Congenital Anomalies: b. Gartner duct cysts c. Mucouc cysts d. Endometriosis e. Benign f. Malignant Cervix a. Inflammations b. Cancer i. Cervical Intraepithelial Neoplasia ii. Squamous cell carcinoma iii. Cancer prevention and control Body of the Uterus and Endometrium a. Endometrial Hormonal Cycle b. Organic abnormalities c. Functional Endometrial Disorders (Dysfunctional Uterine Bleeding) d. Inflammation e. Endometriosis and Adenomyosis f. Endometrial Hyperplasia g. Malignant tumors h. Tumors of Endometrium with Stromal Differentiation i. Tumors of Myometrium Fallopian Tubes a. Inflammations b. Tumors and cysts Ovaries a. Metastatic tumors b. Non-neoplastic and Functional Cysts c. Inflammations Gestaional and Placental Disorders a. Disorders of Early Pregnancy b. Disorders of Late Pregnancy c. Gestational Trophoblastic Disease

January 8, 2011
Urogenital Sinus = Caudal growth & fusion lower vagina Infections y Candida y Trichomonas y Gardnerella y Gonorrhea y Chlamydia y Mycoplasma y Human Papilloma Virus (HPV) Infections in the Lower Genital Tract 1. Herpes Simplex y Vulva, vagina, cervix y HSV-2 y Red painful papules Vesicles Ulcers y Leukorrhea, fever, malaise, tender lymph nodes y Heal spontaneously y Latent infections region nerve ganglia y Neonatal transmission during delivery 2.
y y y y





Mycotic & Yeast (Candida) 10% DM, oral contraceptives, pregnancy Small white surface patches Leukorrhea & pruritus Trichomonas vaginalis Large flagellated ovoid protozoans 15% STD Purulent vaginal discharge, discomfort ³STRAWBERRY CERVIX´ Mycoplasma Vaginitis & cervicitis Spontaneous abortion & chorioamnionitis Gardnerella Gram (-) small bacilli

y y y y


4. y y 5. y


Introduction Embryology th 4 week: primordial germ cells from yolk sac th 5 week: migrate into urogenital ridge Mesoderm epithelium & stroma Endoderm germ cells Mesoderm + endoderm = OVARY th 6 week: invagination & fusion of coelomic epithelium lateral mullerian ducts LATERAL MULLERIAN DUCTS fallopian tubes uterus & vagina

PELVIC INFLAMMATORY DISEASE (PID) y Pelvic pain, adnexal tenderness, fever, vaginal d/c y Gonococcus, Chlamydia, Enteric bacteria y Spontaneous or induced abortion y Puerpural infections: Staphylococcus, Streptococcus, Coliform, C. perfringens y Gonococcal o Bartholin & vestibular glands o Periurethral glands o Cervix o Fallopian Tubes o Acute suppurative reaction o Smears with intracellular gram (-) diplococci o Culture o Acute suppurative salpingitis, salpingoophoritis, tubo-ovarian abscess pyosalpinx, follicular salpingitis y Non-gonococcal o S/P surgery o Lymphatics or venous channels y Staphylococcus, Streptococcus o Less exudation o Inflammation of deeper layers

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o Bacteremia Complications: o Peritonitis o Intestinal obstruction due to adhesions o Bacteremia endocarditis, meningitis, suppurative arthritis o Infertility


Sharply circumscribed nodule in labia majora or interlabial folds HISTO: tubular ducts lined by single or double layers of non ciliated columnar cells with myoepithelial cells

VULVA 1. y y 2. y y y 3. y y y y y 4. y y y y
y y

Inflammatory Dermatologic Diseases Psoriasis, eczema, allergic dermatitis Blood dyscrasia, uremia, DM, malnutrition, avitaminoses Bartholin Cyst Obstruction & infection of Bartholin gland Pain, local discomfort Excised, ³marsupialization´ Vestibular adenitis Posterior introitus Vestibular glands Chronic recurrent, painful Unknown cause Surgery Non neoplastic epithelial disorders ³leukoplakia´ Vitiligo Inflammatory dermatosis Vulvar intraepithelial neoplasia, Paget disease, invasive CA Unknown etiology Lichen sclerosus (Chronic Atrophic Vulvitis) o Pale gray skin, parchment-like o Atrophy of labia o Narrowed introitus o Histology:  Thinning of epidermis  Disappearance of rete pegs  Dense collagenous fibrous tissue  Marked hyperkeratosis  Mononuclear infiltrates about blood vessels o Common after menopause o All ages o Genetic predisposition, autoimmunity, hormonal o 1-4% cancer Lichen simplex chronicus o Acanthosis o Hyperkeratosis o Hyperplais of vulvar squamous epithelium o Increase mitotic activity o Variable WBC infiltration of dermis o May coexist with vulvar epithelial neoplasms Tumors Benign o Fibromas, neurofibroma, angiomas a. Papillary Hidradenoma Modified apocrine sweat glands

b. Benign raised or wart like conditions b.1. Condyloma acuminatum HPV 6& 11 Venereal Wart HISTO: branching tree like proliferations of stratified squamous epithelium, fibrous stroma, acanthosis, parakeratosis, hyperkeratosis, nuclear atypia & perinuclear vacuolation ³koilocytosis´ abscess b.2. Mucosal Polyps Benign stroma proliferations Squamous epithelium b.3. Syphilitic Condyloma latum Elevated red brown spots, popular lesions 23cm

Malignant o Carcinomas, malignant melanoma, sarcoma a. Vulvar Carcinoma Uncommon, 3% of genital ca in females 2/3 >60 years 85% squamous cell carcinoma Remainder: basal cell ca, melanoma, adenocarcinoma Rare Variants: Verrucous CA & Basal Cell CA b. Vulvar Intraepithelial Neoplasia (VIN) White pigmented plaques Nuclear atypia Increase mitosis Lack of surface differentiation Progress to CA depend on age (>45), extent of tumor, immune status Extramammary Paget Disease Rare Vulva, perianal region Pruritic red crusted sharply demarcated map-like area Labia majora- palpable submucosal thickening or tumors Confined to epidermis & adjacent hair follicles, sweat gland neoplasms Histology:  Large tumor cells, lying singly or small clusters, within epidermis & appendages  ³halo´  Fairly granular cytoplasm (+) PAS, alcian blue, mucopolysaccharide Malignant melanoma of vulva Rare <5% of vulvar ca¶s



5. y


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y 1.

2% of melanoma in women 6-7th decade Same biological & histological characteristic as melanoma elsewhere (+) S 100, (-) CEA, S100, mucopolysaccharide


Chronic: mononuclear, lymphocytes, macrophages, plasma cells, necrosis, granulation tissue


2. 3. 4. 5. 6.

Primary disease uncommon Congenital Anomalies: o Atresia o Total absence o Septate or double vagina Gartner duct cysts Mucouc cysts Endometriosis Benign: o Rhabdomyoma, stromal polyps, leiomyomas, hemangiomas, mixed tumors Malignant o Carcinoma, embryonal rhabdomyosarcoma a. Primary Cancer 1% malignant neoplasms 95% squamous cell CA Upper posterior vagina, junction with ectocervix a.1. Adenocarcinoma Rare Increase frequency of young women whose mothers had been treated with DES during pregnancy (0.14% develop adenocarcinoma) Anterior wall, upper 3rd 15-20 years old Vaginal adenosis- precursor HISTO: gland epithelium either mucus secreting, resembling endocervical mucosa or tuboendometrial, with cilia b. Embryonal rhabdomyosarcoma (sarcoma botyroides) Uncommon Infants & children <5 yo (+) embryonal rhabdomyoblasts Gross: polypoid, rounded, bulky masses, fill & project out of vagina ³grape like clusters´ Micro: small oval nuclei, ³tennis racket´, rare striations within cytoplasm, tumor cells in cambium layer, loose fibromyxomatous stroma Invade locally

Endocervical polyps Innocuous tumors 2-5% adult women Irregular vaginal spotting or bleeding Soft, almost mucoid, loose fibromyxomatous stroma, dilated mucus secreting endocrine glands

2. y y y


Cancer th Ranks 8 leading cause of cancer mortality 4500 deaths annually High detection frequency of early cancers & precancerous conditions- Papanicolao cytologic test (PAPS) Risks factors for cervical neoplasia o Early age at first intercourse o Multiple sexual partners o Increased parity o Male partner with multiple previous sexual partner o Cancer associated HPV (16, 18, 31, 33, 35, etc) o Persistent detection of high risk HPV o Certain HLA & viral subtypes o Oral contraceptives & nicotine o Genital infections (Chlamydia) a. Cervical Intraepithelial Neoplasia (CIN) Precancerous stage Continuum of morphologic changes with indistinct boundaries Do not variably progress to cancer & may spontaneously regress Associated with papillomaviruses & high risk HPV types are found in increase frequency in higher grade precursors Classification: a.1. dysplasia/ carcinomain situ system a.2. cervical intraepithelial (CIN) classification a.3. low grade & high grade intraepithelial lesions

CERVIX 1. Inflammations a. Acute & chronic cervicitis Epithelial spongiosis Submucosal edema Epithelial & stromal changes Acute: acute inflammatory cells, eriosion, reactive changes

Cervical Intraepithelial Neoplasia 1. CIN I y Nuclear enlargement, hyperchromasia in superficial cells y Koliocytotic atypia y Raised lesions (acuminatum) & macular (flat condyloma) 2. y CIN II Atypical cells in lower layers of squamous epithelium but with persistent differentiation toward the prickle and keratinizing cell layers Changes in NC ratio, variations in nuclear size, loss of polarity, increase mitotic figures, abnormal mitosis, hyperchromasia CIN III



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y y

Loss of differentiation and greater atypia in more layers of epithelium Totally replaced by immature atypical cells, exhibiting no surface differentiation


Squamous cell carcinoma
y y

y y y y y y y y

Peak incidence: 40-45 years 3 distinct patterns o Fungating (exophytic) ± most common o Ulcerating o Infiltrative Extend by direct spread Local and distant lymph node metastasis Liver, lungs, bone marrow and other structures 95% composed of large cells, either keratinizing or non keratinizing patterns 5% poorly differentiated small cell cacinomas Stage 0 ± IV 10-25%: adenocarcinomas, adenosquamous carcinomas, undifferentiated carcinomas Arise in endocervical glands



Subtle hormonal imbalances: most unexplained Inadequate Luteal Phase o Inadequate corpus luteum function o Low progesterone output o Irregular ovulatory cycle o Manifestations: infertility with eithr increase bleeding or amenorrhea Endometrial changes induced by oral contraceptives o Common response pattern: discordant appearance between glands and stroma, usually with inactive glands amid a stroma showing large cells with abundant cytoplasm reminiscent of the decidua of pregnancy Menopausal and Postmenopausal changes o Atrophy o Mild hyperplasias with cystic dilatation


Cancer prevention and control
y y y y

Cytologic screening and management of PAP smear abnormality Histologic diagnosis and removal of precancers Surgical removal of invasive cancers, with adjunctive radiation and chemotherapy Use of vaccines under investigation

BODY OF THE UTERUS AND ENDOMETRIUM Disorders y Endocrine imbalances y Complications of pregnancy y Neoplastic proliferations 1.
y y y

Endometrial Hormonal Cycle Proliferative ± early, mid, late Secretory Menstrual Organic abnormalities Chronic endometritis Submucosal leiomyomas Endometrial polyp Endometrial neoplasm

Inflammation Acute endometritis o After delivery, miscarriage, retained products of conception o Interstitium inflammation y Chronic endometritis o Chronic PID o Postpartal or postabortal endometrial cavities o Intrauterine contraceptive devices o TB patients: drain TB salpingitis o 15%: no primary cause ± nonspecific chronic endometritis o Chlamydia may be involved 5. Endometriosis and Adenomyosis y 3 theories 1. Regurgitation/implantation theory: retrograde menstruation 2. Metaplastic theory: arise from coelomic epithelium 3. Vascular or lymphatic dissemination theory: disseminated through pelvic veins and lymphatics y Red-blue to yellow brown nodules on or just beneath the serosal surface y Extensive organizing hemorrhage, fibrous adhesions between tubes and ovaries y Obliteration of pouch of Douglas

y y y y


Functional Endometrial Disorders (Dysfunctional Uterine Bleeding) y Anovulatory cycle due to excess estrogen stimulation o Result of: Endocrine disorders: thyroid disease, adrenal disease or pituitary tumors Primary lesions of the ovary: granulosa-theca cell tumors or polycystic ovaries Generalized metabolic disturbance: obesity, malnutrition, chronic system disease

Endometriosis Endometrial glands or stroma in abnormal locations outside the uterus o Ovaries o Uterine ligaments o Rectovaginal septum o Pelvic peritoneum o Laparotomy scars o Umbilicus o Vagina o Vulva o Appendix y Manifestations: infertility, dysmenorrhea, pelvic pain

y y

Adenomyosis Endometrial tissue in uterine wall 20% of uteri

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Shedding of endometrium: colicky dysmenorrhea, dysparenunia and pelvic pain during premenstrual period Endometrial polyps Single or multiple, 0.5 to 3 cm, large, pedunculated Asymptomatic or cause abnormal bleeding Functional endometrium or hyperplastic and cystic


Peak at 40-60

FALLOPIAN TUBES 1. Inflammations y Suppurative salpingitis: 60% gonococcus y Tuberculous salpingitis Tumors and cysts y Paratubal cysts: hyatids of Morgagni y Adenomatoid tumors (mesotheliomas) y Primary adenocarcinoma: rare

y y y


7. Endometrial Hyperplasia Endometrial intraepithelial neoplasia y Increase gland to stroma ratio y Abnormalities in epithelial growth y Prolonged estrogen stimulation by anovulation or increase estrogen production o Menopause, polycystic ovarian disease, functioning granulosa cell tumors of ovary, cortical stromal hyperplasia, prolonged administration of estrogenic substance o Inactivation of PTEN tumor suppresor gene y Simple non-atypical hyperplasia o Cystic, mild hyperplasia y Complex atypical hyperplasia (endometrial intraepithelial neoplasia) o Increase number, size, crowding glands, enlagement and irregular shape common mitotic figures o Treatment: hysterectomy 8. Malignant tumors y Endometrial carcinoma o Most common invasive cance of female genital tract o 7% of invasive cancers in women o Pak age: 55-65 o Higher frequency in obesity, diabetes, HPN, infertility o Gross: localized polypoid tumor or diffuse involving entire endometrial surface o 85% adenocarcinomas: endometrioid type; others: seous type (grade 3) o 3 step grading system: grade 1, 2, 3 9. Tumors of Endometrium with Stromal Differentiation  Carcinosarcomas (malignant mixed mullerian tumors)  Adenosarcomas: benign glands, malignant stroma  Stromal tumors o Benign stromal nodules o Endometrial stromal sarcomas 10. Tumors of Myometrium  Leiomyomas (fibroids) 75% of femaled of reproductive age o Gross: sharply circumscribed, discrete, round, firm, gray white tumors o Microscopic: whorled bundles of smooth muscle cells  Leiomyosarcomas o Bulky fleshy or polypoid masses o Nuclear atypia, mitotic index, zonal necrosis o 10 or more mitosis/10 hpf w/o atypia; 5/10 hpf w/ atypia

OVARIES 1. Inflammations y Oophorits: uncommon 2. Non-neoplastic and Functional Cysts y Follicular and luteal cysts y Polycystic Ovarian Disease (PCOD, Stein-Leventhal syndrome)  3-6% of reproductive women  Numerous cystic follicles or follicle cysts  Associated with oligomenorrhea, persistent anovulation, obesity, hirsutism and rarely virilism y Stromal hyperthecosis (cortical stromal hyperplasia)  Post menopausal women  Uniform enlargement, bilateral  Hypercellular stromal with luteinization of stromal cells  Similar effects as PCOD although virilization may be striking y Theca lutein hyperplasia of pregnancy ± mimick y Classification 1993 WHO o Surface epithelial (mullerian) stromal tumors  Serous ± 30% Tall columnar ciliated epithelial cells Clear serous fluid Psammoma bodies  Mucinous ± 25% Associated with pseudomyxoma peritonei  Endometrioid  Epithelial stromal  Clear cell tumors  Clear cell adenocarcinoma  Cystadenofibroma  Transitional tumors Brenner tumors: transitional cells o Sex cord-stromal tumors  Granulosa-theca cell tumors Call-Exner bodies  Fibro-thecomas  Sertoli-Leydig cell tumors (androblastomas)  Others o Germ cell tumors  Teratomas  Dysgerminoma  Endodermal sinus (Yolk Sac) tumor  Choriocarcinoma  Others o Malignant, NOS (not otherwise specified) o Metastatic Non-ovarian Cancer

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3. Metastatic tumors y Uterus, fallopian tubes, contralateral ovary, pelvic peritoneum y Krukenberg tumor: gastric CA GESTATIONAL AND PLACENTAL DISORDERS Disorders of Early Pregnancy Spontanoues abortions o 10-15% of recognized pregnancies o Fetal and maternal causes y Ectopic pregnancy o 90% tubal o 35-50%: PID w/ chronic salpingitis 2. Disorders of Late Pregnancy y Placental abnormalities and twin placentas y Placental inflammations and infections y Toxemia of pregnancy (preeclampsia and eclampsia) o Hypertension, proteinuria, edema + convulsions o DIC 3. Gestational Trophoblastic Disease y Hyatidiform Mole y Invasive Mole y Choriocarcinoma o Cytotrophoblasts and syncytiotrophoblasts y Placental site trophoblastic tumor (PSTT) o Intermediate trophoblasts


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